by D. B. Carew
“I’m interested in hearing it.” Nathaniel leaned forward.
Chris took a deep breath and exhaled slowly. “I’m standing on the ground, looking up at someone tethered to a hot air balloon. I don’t see a face, but I can tell it’s one of my patients and I’m holding the line as he goes farther up into the sky. The next thing I know, the line slips through my fingers and I’ve lost sight of him. I start panicking that he’s gone forever and that it’s my fault for letting go of the line. That’s when I woke up with my sheets soaking wet.” He laughed nervously. “Told you it was screwed up.”
“What does it mean to you?”
“Well, obviously it’s about work. The hospital’s been in the news a lot recently. I’m working with the guy who’s been charged with killing that ice cream vendor. You know the one?”
Nathaniel nodded. “I’ve read about it.”
“Seems everyone has. Now, I totally sympathize about what happened to Mr. Bianchi. I really do. It was horrible, and I feel bad for his family. But the way Marvin’s been portrayed has also been horrible. The attacks on him in the paper have been vicious. He’d be swinging from a tree right now if some people had their way. They’re calling for him to be locked away for the rest of his life. There’s this perception that he deliberately planned this killing in cold blood, when the reality is that he can’t even plan his next meal, for God’s sake.”
“It sounds like this case has affected a lot of people on a deep, personal level, including you.”
“Well, yeah. I guess what really bothers me is that it’s not just Marvin who’s affected. A case like his reinforces every prejudice out there toward people living with mental health challenges. If we were talking about some other kind of illness, there’d be understanding and support. But when someone in this situation comes into conflict with the law, there’s this skepticism, this feeling that they’re faking illness to avoid jail. I mean, there are people like that —” like Ray, he thought “—but they’re few and far between.”
“Sounds like you’ve been struggling with public perception that stigmatizes the mentally ill and it’s finding its way into your dreams. Going back to your dream for a moment, what do you make of the image of the patient flying away from you?”
“I don’t know. What do you think it means?”
“To me, this dream taps into your feelings of being responsible for your patients and their actions. The fact of the matter is, there’s a limit to how responsible you can be for the actions of any other person.” Nathaniel looked squarely at Chris before continuing. “Whether it’s Ray or one of your patients, there’s only so much you can do and only so much responsibility you should bear.”
“I just hate looking over my shoulder all the time, worrying if they’re safe when they’re out of my sight.”
“When who’s out of your sight? Your patients or your family?”
“Both, actually. On the one hand, I feel deeply connected with Stephanie, but I also fear that I’m putting her safety in jeopardy by continuing with our relationship. The question is, how do I get past this ... this fear?”
“You’re taking a positive step right now by talking about it. Those feelings won’t go away overnight, but you’ll get there.”
“I hope so.”
“Let’s go back to what you said about work. Have you had difficulty concentrating or keeping focussed on a given task?” Chris shook his head. “Have there been instances where you’ve acted in ways that are uncharacteristic?”
“No,” Chris lied. He didn’t feel like disclosing his recent trip to the addresses Marvin had provided out of fear his judgement would rightly be called into question. “I know where you’re headed with this. You’re checking for the severity of my PTSD symptoms.”
“And?”
“And, well, yeah, there’s what happened when I returned to Woodland Park.”
“What about your alcohol intake?”
“I have it under control,” he said, as if trying to convince himself. “The main thing is my sleep: getting to sleep, staying asleep, and not waking up from crappy nightmares all the time. It’s at the point where I dread going to sleep.”
“As we’ve talked about before, sleep problems are common with PTSD. It stands to reason that getting good-quality sleep is going to be critical in addressing your symptoms.”
“I want—I need—to get some decent sleep.” He hesitated before going on. “It’s also becoming an issue with Stephanie and me.”
“How so?”
“Because waking up in the middle of the night, soaking wet with sweat, wakes her up, too. She hasn’t complained, but it’s embarrassing, and it’s getting to the point where I don’t want to sleep in the same bed with her. It sucks.” Chris shook his head in frustration.
“Would you be willing to keep a dream diary so we can discuss your dreams during our meetings?”
“A dream diary?”
“Are you familiar with Imagery Rehearsal Therapy?”
“No.”
“Imagery Rehearsal involves writing down your dreams and nightmares, particularly your recurring ones. Over time, you’ll write and rehearse new endings to those nightmares, but endings that are less traumatic for you. People using this strategy have reported a lower frequency of nightmares, so this may be helpful with yours, particularly the one involving Ray and his rifle. What do you think?”
“It’s worth a try.”
“That’s good to hear.” The counsellor paused, as if searching for the most tactful way to express himself. “Look, Chris, I wouldn’t be doing my job if I didn’t point out a few things you’ve said that concern me.”
Chris shifted his weight in his chair, feeling uncomfortable. “What did I say?”
“For starters, you commented that you thought someone was following you, without any concrete evidence to back that up. I think you may be experiencing what is known as hyperarousal, a constant feeling of being in danger. Given your experience, this would be understandable.”
Chris felt his ears getting hot. He swiped a finger across his forehead to remove a bead of sweat.
“And I asked you about your alcohol intake because you previously acknowledged that after you were attacked by Ray, your drinking patterns changed. You switched from having an occasional beer to regularly drinking rum to excess. Yet today you avoided answering my questions about your drinking altogether. I point this out because it’s important to acknowledge your symptoms.”
Chris reflected for a brief moment. “You’re right. I’ll try to be more open with you.”
“That’s a good note to end on.”
As Chris walked out the building, he received a text from Stephanie. “How was it?”
“Good, but exhausting,” he responded, adding a tired emoji.
On the drive home, Chris drummed his fingers on the steering wheel, feeling good about his session with Nathaniel. He noticed a black Expedition SUV a few cars behind him. It was far enough behind him that he couldn’t make out the licence plate, but he was sure it was the same one he’d seen earlier and felt sick to his stomach at the prospect of being followed. He slowed down before turning right on Burrard Street, as a test, and the Expedition kept going straight.
That had him reflecting on his earlier conversation with Nathaniel. What objective evidence did he have for thinking he was being followed? He wasn’t sure anymore.
SIXTEEN
Another restless night left Chris feeling ill-prepared to handle his next day’s demands. He walked into his office and checked his voicemail. The number of messages waiting for him was generally an accurate indicator of how his day would turn out. Today’s nine messages told him he was in for a rough morning. Setting his messenger bag down, he powered up his computer and started playing back the missed calls.
He soon knew why people were trying so insistently to reach him. Marvin had been involved in an altercation with staff the previous evening and was now in seclusion.
Seclusion rooms were us
ed as a last resort when a patient was considered unsafe to remain on an open unit with his peers and less restrictive options had been exhausted. This was something that usually occurred when the patient was unable or unwilling to follow staff direction and was deemed a risk to himself and others.
He rushed to Alpha Unit. Spotting Alex, he asked what had led to Marvin’s admission to seclusion.
“He had a meltdown,” Alex said in exasperation. In response to Chris’ confused look, he added, “A new patient saw the newspaper on the table, didn’t know it was Marvin’s, and took it. Marvin freaked out, started shouting ‘Home’ over and over and knocking over chairs.”
“Anyone hurt?”
Alex shook his head. “We called Code White and stopped it before it got any further. But we couldn’t reason with him at all. Dr. Stevenson’s on her way here to see whether he’s settled down enough to come out of seclusion.”
Code White was an emergency staff response to aggression, be it patient against patient or patient against staff member. Staff responders were trained in violence de-escalation techniques as well as safe practices in containing a violent situation.
“All of this over a paper? What are the chances of the unit getting two papers, so we can guarantee Marvin gets his own?”
“You know how it goes, Chris. Filling out the paperwork, processing the request. It’ll take a week before we see anything. Meanwhile ...”
“It’s the Tribune he likes. What if I bring in my own for the next few days until the unit gets its second order? I’ll bring it down first thing tomorrow, okay?” He nodded to Dr. Stevenson, who’d entered the nursing station and picked up Marvin’s chart to review the nursing notes.
“Worth a shot. But he’s gonna have to do better than this. He can’t be exploding on us.”
“We’ll tell him that now,” Dr. Stevenson said as she closed the chart and joined the conversation.
Alex gestured patience. “We’re gonna have to wait a few minutes. I don’t have enough staff right now to see Marvin. We’re busy with our new admission in another seclusion room.” Alex explained that a patient named Tim Spirling, admitted the previous evening from Surrey Pre-trial Centre, had verbally attacked another patient without provocation during supper. When staff stepped in to intervene, Tim could not be de-escalated. He had shouted incoherently about the Illuminati and lunged at a nurse. Code White was activated, and nurses and healthcare workers from surrounding units attended Alpha to provide additional support to contain the situation.
“Last night Tim flooded the toilet, and this morning he stripped naked and defecated all over the floor. Dr. Stevenson ordered a shot of Acuphase, which we’re giving now. Hopefully it’ll calm him down.” As Alex said this, Chris heard the seclusion room door close and a collection of staff entered the now-crowded nursing station. “How’d it go?” Alex asked.
A nurse named Danielle shook her head in disbelief. “My hands are still shaking. I could hardly hold the needle still. We’re going to have to move Tim to another seclusion room to give housekeeping staff time to clean the room. There’s crap everywhere.”
Over his years at IFP Chris had seen his share of patients in the throes of an acute psychotic episode. It never ceased to amaze him to see that extreme compared to the same individual once his health had been restored through treatment and rehabilitation. He hoped this would soon be the case with Tim.
Alex looked toward Dr. Stevenson. “We can go see Marvin now.”
They walked through the corridor toward Marvin’s seclusion room. Chris had to hold his nose to block out the stench as they passed Tim’s room. Alex knocked on Marvin’s door. “Marvin, Dr. Stevenson’s here to see you. Please stay on your mattress. Do you understand?”
Marvin didn’t respond, but he remained seated on the bare mattress and made no attempt to get up as the door opened. Dr. Stevenson, Alex, another nurse named Will, and Chris walked into the stark room with bland eggshell-coloured cinder-block walls. Chris noticed the food on Marvin’s breakfast tray hadn’t been touched.
Chris always felt uneasy inside the seclusion rooms. He couldn’t imagine being confined to one, left alone with nothing but a mattress, blanket, toilet, and sink. He reminded himself that for many patients in a highly agitated state, the lack of stimulation in a quiet room actually helped de-escalate the situation.
“Good morning, Marvin. I understand you had a hard time last night,” Dr. Stevenson said. “How are you feeling now?”
Marvin slowly looked at each person in the room, although Chris had the impression that Marvin kept his gaze on him for a split second longer than anyone else. “Home.”
“You want to go home,” Dr. Stevenson acknowledged in a direct but soft voice. “We understand and we’re working on that, but you’re going to have to listen to staff. They’re here to help, so if something is bothering you, you need to tell the nurses.” She paused for a moment, considering Marvin’s cognitive challenges and what she was asking of him. “Or write it down for staff.”
“Write down,” Marvin repeated.
“Yes, that’s good. So, for example, if you can’t find your paper, write that down for staff, and they will help you find it. Do you want to come out of this room?”
Marvin nodded. “Out.”
“Okay, that’s good. First, we’ll give you some time to get a shower. Then we’ll see how you do at snack time with the other patients. If you handle that without any problem, you can return to your room this afternoon. Is that clear?”
He nodded again. “Clear.”
“Do you have any questions?”
Marvin slowly shook his head.
“Does anyone have any questions or anything to say to Marvin?”
No one had anything to add.
“Okay, then. Marvin, I’ll come by to see you later this afternoon.”
“Afternoon.”
The group left the room and congregated in the nursing station to discuss Marvin’s return to the unit.
“We’re not doing him any favours here,” Dr. Stevenson scowled. “He has a number of ritualistic behaviours, and as we’ve seen, he copes very poorly to changes to his routine and environment. He needs a place where an individualized care plan can be consistently carried out. Not a unit with twenty-one other guys and new people coming and going every day.”
Chris knew Marilyn was referring to the NeuroPsych program, which was designed to work with patients with challenges similar to Marvin’s, but that unit wouldn’t be an option for Marvin until his court matter was resolved. “I placed a call with Community Living Society,” Chris responded. “They’ll have to do a review to confirm that Marvin’s needs fall under their mandate, and there’s likely going to be a long waiting list, if he is approved. But I’ve asked them to start the intake process. I’ll keep you updated.”
“Good,” Dr. Stevenson responded. “We need a behavioural consultant to help develop a care plan for Marvin while he’s here. We need to identify his triggers as well as develop strategies to de-escalate Marvin when he’s getting frustrated. Then we need to ensure all staff are familiar with the care plan and carry it out consistently. I’ll have an order available for Ativan to help calm him when he’s starting to get agitated. I’ll also talk with Psychology to see if there’s anything they can suggest. They’re already due to see him for a neuro-psych assessment.”
The rest of Chris’ day was less dramatic: working on a social history for a patient who’d recently been found not criminally responsible on account of a mental disorder, in preparation for his upcoming Review Board hearing, and callbacks to a number of his patients’ families, mostly dealing with the fallout from the hold on community passes. The day flew by.
Despite having reason to feel good about his productivity, Chris felt fatigue and a quiet despair as he drove home. He couldn’t shake the image of Marvin losing control on the unit and he started to second-guess his assessment of his patient. If Marvin’s impulse control was so poor over something as trivial
as missing a newspaper, could he have been provoked into a murderous rage, as the criminal charge against him suggested? He wondered if Brandon was right about him being too close to the case.
SEVENTEEN
Chris was excited Saturday morning as he and Stephanie drove to Deanna’s home to pick up his daughter for their outing. Halfway up the walkway to the house the front door swung open and a jubilant Ann Marie bounded down the walk, her silky brown hair bouncing as she ran, and jumped into his arms. “Where’s Stephanie?”
“She’s waiting in the truck, Sweetie.”
“Can I go see her?”
“Sure. I just need a minute to talk to Mommy and we’ll be on our way.”
Deanna met him at the front entrance. “She’s been looking out the window for you the last thirty minutes.” She smiled. “What time do you think you’ll be back?”
“Is six okay?”
Deanna nodded. “You can always call if you’re running late. I’ll be home anyway.” She waved at her daughter, who was looking back at her parents with a wide grin. “Have a good time.”
Chris saw the smile leave her face. “Is everything okay?”
“Yeah, just a little tired.”
Her response didn’t sound convincing to Chris and he wondered if it had to do with Stephanie’s presence. “You have any plans with Walter?”
“No, not today.”
Whatever the problem was, Deanna didn’t want to talk about it. “Okay, well, we’re off. See you later.”
As they drove into Vancouver, Ann Marie listed all the things she wanted to see at the aquarium. She excitedly asked Chris three times whether she could order waffles at the restaurant, and he joked each time that he wasn’t sure if they still served them. When they finally arrived, Ann Marie made a point of leading Stephanie inside. “This and Wilbur’s are me and my daddy’s favourite restaurants in the whole world!”
“Well, in that case, I feel very lucky to be here,” Stephanie responded with enthusiasm. “What do you want to order?” she added, even though she knew by now what the answer would be.